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Revista chilena de pediatría

Print version ISSN 0370-4106

Rev. chil. pediatr. vol.89 no.2 Santiago Apr. 2018  Epub Apr 06, 2018

http://dx.doi.org/10.4067/s0370-41062018000100185 

ORIGINAL ARTICLE

Parental stressors in a Pediatric Intensive Care Unit

Muriel RamírezA 

Sandra NavarroB 

Cristián ClaveríaC 

Yerko MolinaD  E 

Alfonso CoxF 

A Nurse, Pediatric Critical Care Unit, Clinical Hospital Health Network UC CHRISTUS, Chile.

B Nurse, Mg Social Psychology. Faculty of Medicine, School of Nursing Pontificia Universidad Catolica de Chile, Chile.

C Pediatric Cardiologist and Intensivist, Department of Cardiology and Respiratory Diseases, Division of Pediatrics. Faculty of Medicine Pontificia Universidad Catolica de Chile, Chile.

D Psychologist, Mg Psychology of Health. Faculty of Medicine, School of Nursing Pontificia Universidad Catolica de Chile.

E Academic Faculty of Psychology Adolfo Ibáñez University, Chile.

F Psychologist, Pediatric Critical Care Unit, Clinical Hospital Health Network UC CHRISTUS, Chile.

Abstract:

Introduction:

The hospitalization of a child is a situation that produces a high level of stress on pa rents, especially at the Pediatric Intensive Care Unit (PICU).

Objective:

To determine which are the main stressors perceived by the parents of children hospitalized at PICU and the associated variables.

Patients and Method:

A quantitative, cross-sectional and correlational study, which considers the secondary analysis of data from the IDA project # 201403 of UC School of Nursing: Validation of “The parental stressor scale infant hospitalization in Spanish” (PSSIH modified). Sampling was non probabilistic by convenience, with 217 parents of children at the PICU of a University hospital, who answered a demographic questionnaire and the modified PSSIH instrument to measure stressors in the PICU environment.

Results:

Three dimensions of stressors were identified: Clinical, Emotional and Communication with the professional team. The clinical dimension was the most stressful, with the factors images or sounds, procedures and interventions and the aspect of the child, dimensions related to behavior and communication with the team were less stressful. In addition, it is associated with a greater perception of stress in the different dimensions, when having: previous experiences in PICU, programmed admission, admission due tocardiac pathology, single child, higher educational level and no partner.

Conclusions:

The modified PSSIH instrument made it possible to determine the main stressors perceived by the parents of children in the PICU, the Clinical dimension being the major stressor. These results are useful for developing local intervention programs according to the particular characteristics of the PICU.

Keywords: Pediatric intensive care unit; hospitalized child; parental stressor; humanization of assistance; health facility environment

Introduction

The hospitalization of a child is a situation that produces a high level of stress for parents, especially if it occurs in Pediatric Intensive Care Units (PICU)1-8.

Stress is defined by Weinberg and Richardson, 1981, as the response of an individual when the physi cal or psychosocial demands of a situation exceed the capacity for adaptation9.

The research published to date agree that there are several variables associated with Parental Stress (PS) during childhood hospitalization, which can mani fest itself in response to different stimuli such as: the environment, personal characteristics and individual perception10, nature and course of the child’s disease, hospitalization history, previous material and personal resources, the available help, among others11. Accor ding to the literature12, these factors or stressors can be grouped into factors derived from the child, the pa rents, the environment and the clinical team.

Factors derived from the child

These seem to be the most stressful for parents1,2,13-16, such as those related to the signs and symptoms of childhood disease, the physical appea rance of the child, the presence of devices and restra ints, among others11,17-19.

Factors derived from parents

Chourasia et al. 2013, consider that the most im portant factor for triggering PS is the alteration of the paternal/maternal role, secondary to hospitalization18. Also, altered family functioning, sense of disbelief, guilt, frustration, anxiety, anger, and fear are described, which can develop stress and depression in parents, due to their apparent inability to resolve the situation4,11,20,21. The loss of the parental role in the PICU is an important factor in the generation of stress1,3,5,6,22,23, related to the separation of their child and the inability to care for and protect him/her24,25.

Factors derived from the environment

In this context, technological assistance is descri bed, as well as aspects of the hospital environment such as odors, alarms, lights, environmental noise and a lar ge number of people within the unit2,4,19,22,26,27.

Factors derived from the health team

Overly rapid explanations and the use of technical words by professionals are described as stressful, as well as the lack of attention when the professional is re quired, not knowing the members of the health team, among others2,11.

Stress has been evaluated in Neonatal and Pedia tric ICUs1,16,18,19,28, however, in general, the results are measured, that is, the level of stress produced in the pa rents, but what are the factors that trigger such stress in parents? To date, there is no publication of an instru ment validated in Spanish, which solves this question and allows to carry out programmed and preventive changes in environmental management and relation ship with parents, according to the local reality of the PICU.

To measure the perception of parental stressors in the PICU, there is the English instrument “The Parental Stressor Scale: Infant Hospitalization (PSS: IH), created by Miles et al (1985), modified by Saied29, which was submitted by this team in the first instance to a rigorous process of instrumental validation.

The objective of this study was to determine what are the main perceived stressors and what variables are associated with this perception? in caregivers of pa tients hospitalized in the PICU, of a university hospital.

Patients and Methods

Descriptive, observational, cross-sectional study, product of the secondary data analysis of the project Validation of “The Parental Stressor Scale Infant Hos pitalization, into Spanish” (PSSIH) modified.

The target population corresponds to parents of children hospitalized in a PICU that cares for children with various pathologies, however, it has a large per centage of patients with heart surgery, because it is a referral center for the resolution of congenital heart diseases. The range of ages ranges from 0 to 14 years of age, with some exceptions, such as cases of chronic patients.

Sampling was non-probabilistic for convenience and the final sample consisted of 217 participants, who met the following inclusion criteria: being over 18 years of age, being the father or mother of a child hospitalized for at least 48 hours in the PICU. Pa rents with a diagnosis or situation that could alter their perception of reality, registered in the clinical record, were excluded from the sample. All subjects agreed to participate, after signing the Informed Consent.

The instruments applied were a demographic ques tionnaire and the modified PSSIH, to measure stres sors in the PICU environment.

For the data analysis, descriptive statistics were used and for the evaluation of associations, T-Student and Pearson correlation were used, depending on the level of measurement of the variables.

The study was approved by the local Ethics Com mittee.

Results

Child characteristics

The age of the children involved was from 0 -18 years, with an average of three years and a standard de viation of 4.3. Most of them were male (53.2%); 44% were hospitalized for the first time, highlighting 34% with three or more hospitalizations. 61.5% were ad mitted on a programmed basis. The reasons for hospi talization were due to cardiac problems (60%), neuro logical problems (14.2%) and the remaining percenta ge was distributed among oncological, respiratory and other problems.

Caregiver characteristics

Regarding the participants, the ages ranged from 18 to 61 years, with an average of 34.6 and a standard deviation of 8.14. Most of them were mothers (61%); university-level education (37.8%), with graduate stu dies (10.6%) and technical level education (24.9%). Regarding marital status, they declared to be married (53.4%), single (40.6%) and practically two-thirds of the sample (64.5%) also have another child. The vast majority declare having a paid job (78.4%). The highest percentage lives in the Metropolitan Region (57.6%), only 6% live in rural areas.

Descriptive for the factors and dimensions of stressors

The Scale of Assessment of Parental Stressors in PICU consists of three dimensions, which include a se ries of situations that can be considered as stressful for parents during the hospitalization of their child:

Clinical dimension, which includes stressors: the appearance of the child; images or sounds; procedures or interventions; health team behavior.

Emotional dimension, which considers: behavior and/or emotional child response; parents role.

Communication dimension with the health team. It is observed that the dimension that causes the most stress in the parents corresponds to the Clinic presen tation, followed by the Emotional and finally the Com munication with the Health Team. In addition, the Clinical dimension presents less dispersion (Table 1).

Table 1 Descriptions for stressors according to factor and dimension. 

Regarding the stressors in the Clinical dimension, the “images or sounds” are those that generate more stress in the parents, then there are the “procedures and interventions” and the “aspect of the child”. The “behavior of the health team” is the factor that gene rates less stress.

In relation to the Emotional dimension, both stres sors, “emotional response of the child” and “role of pa rents”, present similar levels, with a slight increase for “emotional response of the child”.

The characteristics of the sample, the stressful con dition of each dimension and the stressors by dimen sion were analyzed, obtaining the following results:

In the stressors “procedures and interventions”, “emotional response of the child” and “role of the pa rents”, the participants who had previous experiences of hospitalization of their children in a PICU, declared to be stressed more (Table 2).

Table 2 Comparative analysis according to experience, form of income and cause of hospitalization for the factors and dimen sions of stressors (only the factors in which significant differences were found are shown). 

Regarding the type of admission, programmed or emergency, two stressors were presented with greater impact: “aspect of the child” and “procedures and in terventions”, which are increased in those parents who se children entered on a programmed basis (Table 2).

According to the cause of hospitalization, it is ob served that the parents of children admitted with car diological problems declare a greater stressor quality in relation to “aspect of the child”, “procedures and interventions” and “role of parents”. On the other hand, the “behavior of the health team” and “commu nication with the health team”, show with less stressful quality (Table 2).

Regarding kinship, it is observed that the stressor “procedures and interventions” is generating a greater perception of stress in mothers (Table 2).

On the other hand, participants with a university or postgraduate educational level tend to perceive grea ter stress derived from the “health team behavior” and the “communication with the health team” dimension (Table 2).

It is also observed that participants who declare not having a partner at the time of the study, perceive greater stress with respect to the stressors “aspect of the child” and “procedures and interventions”, present in the Clinical dimension (Table 3).

Table 3 Comparative analyzes according to couple and single hospitalized child for the factors and dimensions of stressors (only the factors in which significant differences were found are shown). 

In addition, the parents of single children perceive greater stress derived from the “behavior of the health team” and the “communication with the health team” (Table 3).

When considering the ages, it is observed that at a younger age of both the participants and their chil dren, there is a greater perception of parental stress re garding the “appearance of the child”, “procedures and interventions” and “role of parents” (Table 4 and 5).

Table 4 Age. Significant correlations for age in months with the factors and dimensions of stressors. 

Table 5 Significant correlations for age of the care giver with the factors and dimensions of stressors. 

Discussion

For those who work in highly complex services such as a PICU, which demands a high demand not only from the child as a patient, but also from parents, it is essential to know the psychosocial reality of their immediate environment, considering that they will in fluence the coping that they have with the disease, hospitalization, and recovery of their child, as well as their active participation in the care and recovery.

Concordant with what is stated in the literature1,2,13,16, the Clinical dimension and everything related to the “aspect of the child” and the “images or sounds” is what would cause the most stress in the parents. On the other hand, within this clinical dimension, in the stressor “procedures and interventions”, parents say that it would be a great relief for them to be able to stay with their children during most of the procedures. This is an aspect to consider for each unit, where the feasibility that parents can voluntarily stay should be evaluated if they prefer.

Frequently in clinical work it is stated that the pre vious experience of hospitalization in parents and children would be a protective factor against stress, for the learning that has meant, however, in the present study it was observed that parents of children with more of a hospitalization in the PICU present more stress in relation to the “procedures and interventions”, “emo tional response of the child” and “role of parents”. As a result, parents feel more concern about a current hospitalization, due to what has been experienced or observed in other patients, they know the risks implicit in a PICU stay.

Similar situation occurs with the variable “pro grammed hospitalization” versus “emergency hospitalization”, the possibility of anticipating hospitaliza tion would allow parents and eventually their children to prepare both in practical aspects such as changing family routine and functioning, psychological aspects and emotional, in front of what it means to have an ill child hospitalized30. This logical thinking is contra dicted by the results obtained, which indicate greater stress in the “appearance of the child” and “procedures and interventions”, in the case of programmed hospi talizations. This could be explained by considering that 60% of the children involved in the study were hos pitalized for a cardiological reason, often as a conse quence of performing cardiac surgery, which although is programmed, in most cases, comes implicitly a great emotional burden due to the eventual severity in its evolution.

Likewise, in this group of patients with cardiolo gical problems, it was observed that their parents re ported being less stressed by the factors “health team behavior” and “communication with the health team”, probably because they know in advance the treating team, for consultations and/or previous surgeries. In this regard, the literature states that an important fac tor for parents is to maintain a relationship of trust with the health team and stay informed31, it is also su ggested that knowing the health team beforehand can reduce levels of anxiety and reduce possible conflicts between the health team and parents21,22,24.

Another result is that there is no significant di fference between the days of hospitalization and the various factors and dimensions of the instrument. Re garding the hospitalization duration, some researchers describe it as a predisposing factor for PS1,2,11. It could be thought that the more days of stay in the PICU, both children and their parents, accumulate fatigue, anxiety, uncertainty, etc., which would mean greater sensitivity to environmental stressors, or, that with the passage of days, learning from the experience could reassure parents and facilitate their dynamics in the PICU, none of these two hypotheses are consistent with the results obtained, so it would be interesting to explain this di fference.

The greater stress experienced by mothers versus fathers in the factor “procedures and interventions” could be due to the fact that mothers usually stay longer during the day with their children in the unit and it is during the day in which they occur, greater number of consultations to specialists, examinations and procedures, therefore, it is the mother who has to observe and interact with the health team. It would be interesting to know if this decision, for example, is in common agreement or if it would be different in other social and cultural realities.

Regarding the educational level, the greater stress experienced by fathers or mothers with more education, could be explained by more access to informa tion, knowledge of the disease of their child, understanding of the objectives of the examinations and treatments applied, which would be a factor of tension of the relationship with the professionals of the unit. A systematic review32 refers that parents emphasize the importance of the relationship established with health professionals, the competence of them to incorporate them into decision making, allowing them to carry out their parental role.

Finally, it should be noted that one of the limita tions of the study is the external validity, because the place where this research was conducted has specific characteristics, as it is a referral center of congenital heart diseases, which individualize the results more than what is desired.

Conclusions

The modified instrument “The Parental Stressor Scale Infant Hospitalization, into Spanish” (PSSIH) allowed determining the main stressors perceived by parents of children hospitalized in the PICU, where the Clinical dimension is the greatest stressor.

The results obtained in this study could guide on the aspects to be improved in favor of less stress for parents, considering the local reality, with measures such as education and emotional support, which have shown positive effects in decreasing the level of paren tal stress25,33.

Likewise, it is necessary that each PICU can evaluate its reality, with the instrument “The Parental Stressor Scale Infant Hospitalization, into Spanish” (PSSIH) modified and validated for the Chilean population, with the purpose of carrying out actions of continuous improvement in the care of the child hospitalized in the PICU and their parents.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed according to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regulations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Financial Disclosure: Research Project for the Teaching and Training Inte gration, IDA-201403. School of Medicine, School of Nursing. Pontifical Catholic University of Chile.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Aknowledgments: We thank the parents of the patients, who despite li ving a difficult process during the hospitalization of their child, accepted to participate selflessly by answe ring the instrument.

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Received: July 11, 2017; Accepted: November 02, 2017

Correspondence: Sandra navarro T. enavarrt@uc.cl.

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